Outcomes of 262 Consecutive HLA-incompatible Renal Transplants

Introduction: Sensitization to allo-HLA remains one of the most recalcitrant problems in renal transplantation. Methods: 262 patients underwent HLA-incompatible live donor kidney transplantation, as identified by positive cytotoxic or flow cytometric crossmatch and/or detectable DSA by solid-phase immunoassays between February 1998 and October 2011. All patients were desensitized with a standard protocol consisting of every other day plasmapheresis followed by low dose CMVIg (100 mg/kg). Results: The transplant rate for the 266 patients that started preconditioning was 98.5% (4 patients did not adequately deplete DSA). 55.0% of the patients had at least 1 previous failed kidney transplant, with 16.0% receiving their 3rd, 4th, or 5th transplant. The median cytotoxic cPRA was 88.5% (IQR 68-100%). Median years of renal replacement were 6.6 (IQR 2-15 yrs). The median numbers of pre- and post-transplant plasmapheresis sessions were 3 (IQR 2-5) and 4 (IQR 2-7), respectively. The serum creatinines at 1 week, 1 year, 3 years, 5 years, and current were 1.35, 1.2, 1.2, 1.3, and 1.25 mg/dl. 82% of patients had a cg=0 score on 1 year protocol biopsies. Cellular and AMR rates were 41% and 22%. Patient and graft survival rates at 1, 3, and 5 years were 91.3%, 86.3%, 79.8% (Fig 1A) and 93.3%, 88.6%, 82.3% (Fig 1B).[Figure 1]Conclusion: Desensitization using plasmapheresis and low dose IVIg has a high transplant rate and produces durable graft function with lower rates of AMR and transplant glomerulopathy than previously reported in smaller series. It is estimated that this protocol could enable an additional 2,000 live donor transplants each year.